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Assessment and management of hypertension in children and adolescents

Nature Reviews Cardiology volume 7, pages 155–163 (2010)Cite this article

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Abstract

The epidemic of overweight and obesity in youth is increasing the prevalence of prehypertension and hypertension among children and adolescents. The younger the child is at presentation and the more severe the blood pressure abnormality, the more likely a secondary cause of hypertension is to be present. Measurement of blood pressure in children requires adaptation to the age and size of the child. Interpretation must be related to normative values specific for age, sex, and height. Evaluation is primarily aimed at identifying secondary causes of hypertension, associated comorbidities, additional risk factors, and evidence of target-organ damage. Ambulatory blood pressure monitoring is emerging as a useful tool for evaluation of some patients, particularly for those with suspected 'white coat' hypertension. Management of prehypertension and hypertension is directed at the underlying cause, exacerbating factors, and the magnitude of the blood pressure abnormality. Healthy behavioral changes are a primary management tool for treating hypertension and, more particularly, prehypertension and for addressing other cardiovascular risk factors, such as obesity. Pharmacological management is reserved for patients with hypertension who do not respond to behavioral changes, have additional cardiovascular risk factors or diabetes, are symptomatic, or have developed target-organ damage.

Key Points

  • The epidemic of youth obesity is increasing the prevalence of hypertension, primarily related to the metabolic syndrome, which accelerates atherosclerosis and increases the likelihood of target-organ damage

  • While primary hypertension is more prevalent in older children and adolescents, secondary hypertension is more prevalent in infants and younger children and those with more severe blood pressure elevation

  • Accurate blood pressure measurement in children requires attention to technique, particularly the use of the appropriate cuff size matched to the size of the child's extremity

  • For children, blood pressure measurements must be related to population-derived percentile levels based on sex, age, and height, which inform definitions of prehypertension and hypertension

  • Ambulatory blood pressure monitoring can be useful in assessing 'white coat' and masked hypertension, blood pressure variability, children at high risk of cardiovascular disease, and effectiveness of antihypertensive agents

  • Lifestyle behavioral change is the cornerstone of management, but clinical trials of pharmacological agents in children have expanded the armamentarium for those patients who meet criteria for antihypertensive treatment

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Figure 1: Prevalence of prehypertension and hypertension in the US between 1988 and 2006 among children aged 8–17 years.
Figure 2: Management algorithm for blood pressure categories in children and adolescents.

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Acknowledgements

Désirée Lie, University of California, Orange, CA is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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    Brian W. McCrindle

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The author, the Journal Editor B. Mearns and the CME questions author D. Lie declare no competing interests.

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McCrindle, B. Assessment and management of hypertension in children and adolescents. Nat Rev Cardiol 7, 155–163 (2010). https://doi.org/10.1038/nrcardio.2009.231

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